A risk score for predicting perioperative blood transfusion in liver surgery

BACKGROUND: It would be desirable to predict which patients are most likely to benefit from preoperative autologous blood donation. This aim of this study was to develop a point scoring system for predicting the need for blood transfusion in liver surgery. METHODS: The medical records of 480 consecutive patients who underwent hepatic resection were analysed. The data set was split randomly into a derivation set of two-thirds and a validation set of one-third. Univariable analysis was carried out to determine the association between clinicopathological factors and blood transfusion. Significant variables were entered into a multiple logistic regression model, and a transfusion risk score (TRS) was developed. The accuracy of the system was validated by calculating the area under the receiver-operator characteristic (ROC) curve. RESULTS: Factors associated with blood transfusion in multivariable analysis included preoperative haemoglobin concentration below 12.5 g/dl, largest tumour more than 4 cm, need for exposure of the vena cava, need for an associated procedure, and cirrhosis. Each variable was assigned one point, and the total score was compared with the transfusion status of each patient in the validation set. The TRS accurately predicted the likelihood of blood transfusion. In the validation set the area under the ROC curve was 0.89. CONCLUSION: Use of the TRS could lead to substantial saving by improving the cost-effectiveness of the autologous blood donation programme.     

Effects of the combination of blood transfusion and postoperative infectious complications on prognosis after surgery for colorectal cancer. Danish RANX05 Colorectal Cancer Study Group

BACKGROUND: The frequency of postoperative infectious complications is significantly increased in patients with colorectal cancer receiving perioperative blood transfusion. It is still debated, however, whether perioperative blood transfusion alters the incidence of disease recurrence or otherwise affects the prognosis. METHODS: Patient risk variables, variables related to operation technique, blood transfusion and the development of infectious complications were recorded prospectively in 740 patients undergoing elective resection for primary colorectal cancer. Endpoints were overall survival (n = 740) and time to diagnosis of recurrent disease in the subgroup of patients operated on with curative intention (n = 532). The patients were analysed in four groups divided with respect to administration or not of perioperative blood transfusion and development or non-development of postoperative infectious complications. RESULTS: Overall, 19 per cent of 288 non-transfused and 31 per cent of 452 transfused patients developed postoperative infectious complications (P< 0.001). The median observation period was 6.8 (range 5.4-7.9) years. In a multivariate analysis, risk of death was significantly increased among patients developing infection after transfusion (n = 142) compared with patients receiving neither blood transfusion nor developing infection (n = 234): hazard ratio 1.38 (95 per cent confidence interval (c.i.) 1.05-1.81). Overall survival of patients receiving blood transfusion without subsequent infection (n = 310) and patients developing infection without preceding transfusion (n = 54) was not significantly decreased. In an analysis of disease recurrence the combination of blood transfusion and subsequent development of infection (hazard ratio 1.79 (95 per cent c.i. 1.13-2.82)), localization of cancer in the rectum and Dukes classification were independent risk factors. CONCLUSION: Blood transfusion per se may not be a risk factor for poor prognosis after colorectal cancer surgery. However, the combination of perioperative blood transfusion and subsequent development of postoperative infectious complications may be associated with a poor prognosis.     

Meta-analysis of sentinel node imprint cytology in breast cancer

BACKGROUND: Intraoperative diagnosis of breast cancer metastases in axillary sentinel nodes is desirable to avoid a second operation for lymphadenectomy. Imprint or touch-preparation cytology is a popular technique that has high specificity and a wide range of sensitivity. METHODS: A systematic search of electronic databases was performed. Included articles were assessed for methodological and reporting quality. Random-effects model pooled estimates of sensitivity and specificity were calculated. Single-variable and multivariable meta-regression analyses were performed for predictors of sensitivity. RESULTS: Thirty-one studies were included; all were of good methodological quality but reporting quality varied. Pooled sensitivity of imprint cytology was 63 (95 per cent confidence interval (c.i.) 57 to 69) per cent and specificity was 99 (95 per cent c.i. 98 to 99) per cent. Pooled sensitivity for macrometastases was 81 per cent and that for micrometastases 22 per cent. Mean or median primary tumour size (P = 0.004), the prevalence of metastases (P = 0.103) and the proportion of micrometastases (P = 0.022) were significant risk factors in single-variable meta-regression analysis. Only the proportion of micrometastases remained significant in multivariable analysis. Frozen sectioning had better sensitivity than imprint cytology in three of four direct comparisons. CONCLUSION: Imprint cytology is simple and rapid, and has good sensitivity for macrometastases. The significance of poor sensitivity for micrometastases will be determined by trials investigating their natural history.     

Economic evaluation of a randomized clinical trial of haemodilution with cell salvage in aortic surgery

BACKGROUND: This study evaluated the costs of acute normovolaemic haemodilution (ANH) and intraoperative cell salvage (ICS) versus homologous blood transfusion in aortic surgery in a prospective multicentre randomized trial. METHODS: One hundred and forty-five patients were randomized either to standard transfusion practice (homologous) or to a combination of ANH and ICS (autologous). Costs for each inpatient admission were identified. Cell salvage costs were assigned on the assumption that 50 operations were done each year employing a trained cell salvage operator. The results were analysed statistically using bias-corrected bootstrap analysis. RESULTS: Patients who had transfusion of homologous blood received some 251 units and those having a homologous transfusion received 103 units (P = 0.008). There was no difference in morbidity, mortality and duration of hospital stay. Transfusion-related mean costs were similar at 340 UK pounds for patients having a homologous transfusion and 357 UK pounds for those receiving autologous blood (mean difference 17 UK pounds (95 per cent confidence interval [c.i.]--184 UK pounds to 174 UK pounds); P not significant). There was also no significant difference in mean overall costs: 5859 UK pounds for homologous and 5384 UK pounds for autologous transfusion (mean difference--475 UK pounds (95 per cent c.i.--2231 UK pounds to 1342 UK pounds)). Sensitivity analysis showed that costs remained similar for 20 and 150 operations per annum. Exclusion of a dedicated cell salvage operator reduced autologous transfusion costs but did not have a significant impact on overall cost. CONCLUSION: Autologous transfusion is cost neutral in aortic surgery even when surgical activity is low.     

Systematic review of the use of fibrin sealant to minimize perioperative allogeneic blood transfusion

BACKGROUND: Fibrin sealants have become popular in improving perioperative haemostasis and reducing the need for allogeneic red cell transfusion. METHODS: A systematic review of randomized controlled trials was conducted to examine the efficacy of fibrin sealants in reducing perioperative blood loss and allogeneic red blood cell transfusion. Studies were identified by computer searches of Medline, Embase, Current Contents, the Cochrane Library, manufacturer websites (to January 2001), and bibliographic searches of published articles. Trials were eligible for inclusion if they involved adult elective surgery and reported quantitative data on blood loss, the proportion of patients exposed to allogeneic red cell transfusion and/or the volume of blood transfused. RESULTS: Twelve trials met the criteria for inclusion. Fibrin sealants reduced the rate of allogeneic blood transfusion (relative risk 0.40 (95 per cent confidence interval (c.i.) 0.26 to 0.61); five trials with 275 subjects) and reduced blood loss (weighted mean difference--151.68 (95 per cent c.i. - 251.91 to - 51.46) ml; seven trials with 391 subjects). Generally, the trials were small and of poor methodological quality. CONCLUSION: Overall the results suggest that fibrin sealants are efficacious. Owing to lack of blinding, transfusion practices may have been influenced by knowledge of the patient's treatment status. This raises concern about blood transfusion practice as a response variable. Large methodologically rigorous trials of fibrin sealants with clinical outcomes are needed.     

Recurrence and survival after mesorectal excision for rectal cancer

BACKGROUND: Mesorectal excision for rectal cancer has resulted in local recurrence rates of 3-11 per cent compared with up to 38 per cent after conventional methods. The results of a prospective Danish study with a historical control group are presented. METHODS: Three hundred and eleven patients with a mobile rectal cancer had mesorectal excision with curative intent performed by certified surgeons and were followed for 3 years. Demographic, perioperative and follow-up data were recorded prospectively. A series of patients who had conventional operations for rectal cancer served as a control group. RESULTS: The cumulative 3-year local recurrence rate was 11 per cent after mesorectal excision compared with 30 per cent after conventional surgery (hazard ratio (HR) 0.33 (95 per cent confidence interval (c.i.) 0.21 to 0.52); P < 0.001). Multivariate regression analysis showed that only advanced age (HR 0.97 (95 per cent c.i. 0.94 to 1.00); P = 0.048) and tumour in the lower third of the rectum (HR 0.21 (95 per cent c.i. 0.04 to 1.97); P = 0.075) were marginal independent predictors of local recurrence after mesorectal excision. The cumulative crude 3-year survival rate was 77 per cent after mesorectal excision and 62 per cent after conventional surgery (HR 0.58 (95 per cent c.i. 0.43 to 0.77); P < 0.001). Age was the only independent predictor of death after mesorectal excision (HR 1.04 (95 per cent c.i. 1.02 to 1.07); P = 0.001). CONCLUSION: Mesorectal excision is associated with a considerably lower risk of local recurrence and a better survival rate than conventional surgery, and is the optimum method for rectal cancer resection.     

Ranitidine as adjuvant treatment in colorectal cancer

BACKGROUND: Results from short-term studies of histamine type 2 (H2) receptor antagonists on survival of patients with solid tumours are debatable. In this study the efficacy of the H2-receptor antagonist ranitidine on long-term survival of patients with colorectal cancer was evaluated. METHODS: Patients scheduled for elective resection of primary tumours were consecutively included in a randomized double-blind placebo-controlled clinical study designed to evaluate the effect of ranitidine on survival. Before skin incision ranitidine 100 mg or placebo was given intravenously twice daily followed by oral ranitidine 150 mg or placebo twice daily for 5 years. Adjuvant cytotoxic or radiation therapy was not given. An observer-blinded interim analysis performed after 40 months showed that there was no effect of ranitidine on overall survival, and the study was discontinued in accordance with the protocol. The patient cohort has been followed continuously without loss of any patient, and a final statistical analysis was performed on an intention-to-treat basis after more than 5 years; this included a subgroup analysis of perioperative blood transfusion and postoperative infectious complications. RESULTS: The median observation period of the 740 patients included was 6.8 (range 5.4-7.9) years. A univariate analysis of all 740 patients and of the subgroup of 560 who underwent curative resection showed no significant effect of ranitidine on survival. Furthermore, ranitidine had no survival benefit in curatively resected patients who received a perioperative blood transfusion (n = 358), but it improved the survival of non-transfused patients (n = 202; hazard ratio (HR) 0.6 (95 per cent confidence interval (c.i.) 0.4 to 0.9), P = 0.02) and of non-transfused patients who did not develop postoperative infectious complications (n = 170; HR 0.6 (95 per cent c.i. 0.4 to 0.9), P = 0.01). In multivariate analysis of patients who had a curative resection, including Dukes' stage, age, gender, tumour location, blood transfusion, postoperative infectious complications and treatment, ranitidine still had an independent, beneficial effect on survival (HR 0.6 (95 per cent c.i. 0.4 to 1.0), P = 0.04) within the subgroup of patients who did not receive perioperative blood transfusion and did not develop postoperative infectious complications. CONCLUSION: Ranitidine may prolong the survival of patients who undergo curative resection of colorectal cancer and who do not receive perioperative blood transfusion and do not develop postoperative infectious complications.     

B-type natriuretic peptide predicts cardiac morbidity and mortality after major surgery

BACKGROUND: The objective of this study was to determine whether measurement of B-type natriuretic peptide (BNP) concentration before operation could be used to predict perioperative cardiac morbidity. METHODS: A prospective derivation study was performed in high-risk patients undergoing major non-cardiac surgery, with a subsequent validation study. A venous blood sample was taken the day before surgery for measurement of plasma BNP concentration. Screening for cardiac events (non-fatal myocardial infarction and cardiac death) was performed using clinical criteria, cardiac troponin I analysis and serial electrocardiography. RESULTS: Forty-one patients were recruited to the derivation cohort and 149 to the validation cohort. In the derivation cohort, the median (interquartile range) BNP concentration in the 11 patients who had a postoperative cardiac event was 210 (165-380) pg/ml, compared with 34.5 (14-70) pg/ml in those with no cardiac complications (P < 0.001). In the validation cohort, the median BNP concentration in the 15 patients who had a cardiac event was 351 (127-1034) pg/ml, compared with 30.5 (11-79.5) pg/ml in the remainder (P < 0.001). BNP concentration remained a significant outcome predictor in multivariable analysis (P < 0.001). Using receiver-operator curve analysis it was calculated that a BNP concentration of 108.5 pg/ml best predicted the likelihood of cardiac events, with a sensitivity and specificity of 87 per cent each. CONCLUSION: Preoperative serum BNP concentration predicted postoperative cardiac events in patients undergoing major non-cardiac surgery independently of other risk factors.     

Validation of a clinical prediction rule to reduce preoperative type and screen procedures

Background. We have developed a prediction rule for the occurrenceof perioperative red blood cell transfusion to help to reducethe number of unnecessary preoperative type and screen procedures.We evaluated the robustness of this prediction rule in patientsfrom another hospital. Methods. The rule was retrospectively applied to 1282 consecutivepatients (‘validation set’) who underwent similarsurgical procedures to the patients in the derivation study.The outcome was similarly defined as any allogeneic transfusionon the day of surgery or during the first postoperative day.The predictive value of the rule was assessed using a ReceiverOperating Characteristic curve (ROC) and compared with the resultsof the derivation study. Subsequently, the number of correctlypredicted transfusions was compared. Results. The patient characteristics did not differ betweenthe two sets, except for the incidence of transfusion (derivationstudy: 18%; present study: 8%). In the validation set, the ROCarea of the prediction rule was 0.78 (95% confidence intervals[CI]: 0.73–0.82), which was within the CI of the ROC areafound in the derivation study (0.75; 95% CI: 0.72–0.79).In total, 35% of the type and screen procedures could be omitted(derivation study: 50%), with 13% missed transfused patients(derivation study: 20%). Conclusions. After comparing the results of this validationstudy with that of the derivation study, the prediction rulewas robust and may work in other clinics as well. Br J Anaesth 2002; 88: 221–5     

Risk factors for perioperative morbidity and mortality after extended hepatectomy for hepatocellular carcinoma

BACKGROUND: Extended hepatectomy with resection of more than four segments is a high-risk operation, especially in patients with hepatocellular carcinoma (HCC) associated with chronic liver disease. This study evaluated the risk factors for morbidity and mortality following extended hepatectomy for HCC. METHODS: Preoperative and intraoperative variables of 155 patients who underwent extended hepatectomy for HCC were analysed to identify risk factors for postoperative morbidity and mortality. RESULTS: The overall morbidity rate was 55.5 per cent (n = 86). Most morbidity was due to ascites or pleural effusion. Significant life-threatening complications occurred in 20.0 per cent (n = 31). The perioperative mortality rate was 8.4 per cent (n = 13). Multivariate analysis found that portal clamping (P = 0.023) and perioperative blood transfusion (P < 0.001) were risk factors for morbidity, whereas perioperative blood transfusion (P < 0.001) was the only risk factor for significant morbidity. Co-morbid illness (P = 0.019) and perioperative blood transfusion (P = 0.004) were risk factors for perioperative mortality. CONCLUSION: Meticulous operative techniques to minimize blood loss and transfusion, while avoiding a prolonged Pringle manoeuvre, may help reduce postoperative morbidity. Avoidance of perioperative blood transfusion and careful preoperative selection of patients in terms of overall physiological status are important measures to reduce the postoperative mortality rate.     

Solicitud de sangre preoperatoria en cirugía programada de colon: ¿necesidad o rutina?

Background

Preoperative blood ordering is frequently in elective colon surgery, even for procedures that rarely require blood transfusion. Most often this procedure is performed without proper analysis of the real needs. The aim of this study was to evaluate the patients who receive transfusion and determining their associated factors.

Methods

Retrospective study of all consecutive patients scheduled for elective colon surgery was carried out at 2007-2012. Several clinico-pathological and surgical variables were analyzed and predictive blood transfusion indices such as the cross-matched/transfusion ratio (C/T ratio), transfusion index and transfusion probability were calculated. Patients were divided in 2 groups according have received perioperative surgical transfusion or not.

Results

There were 457 surgery patients. A total of 171 blood units, in a 74 patients were perioperative transfused. Overall cross-matched transfused ratio was 5.34, the transfusion probability 162%, and the transfusion index 0.18. Variables that were significantly associated with receiving blood transfusion in a multivariable analysis were a preoperative haemoglobin level less than 10 g/dl (OR: 309.8; 95% CI: 52.7-985.2), chronic pulmonary obstructive disease (OR: 3.7; 95% CI: 1.3-10.7), oral anticoagulant therapy (OR: 5.7; 95% CI: 1.7-19.4) and surgical time over 120 min (OR: 10.7; 95% CI: 4.7-24.1).

Conclusions

Likelihood of receiving perioperative transfusion in elective colon surgery is very low. Among their associated factors, the haemoglobin level less than 10 g/dl is the one with strongest association. Those patients with such low preoperative haemoglobin level should not be scheduled for elective colon surgery until they received specific treatment.     

Identification of risk factors for allogenic transfusion in cardiac surgery from an observational study

OBJECTIVE: To determine perioperative variables for predicting allogenic transfusion in adult cardiac surgery. STUDY DESIGN: Prospective study. PATIENTS: We included 335 consecutive patients undergoing cardiac surgery between February and April 2001. METHODS: Perioperative variables were prospectively collected in a database. For each patient who received transfusion, hemoglobin threshold for transfusion and total number of units of red cell concentrates were collected. Univariate and multivariate analysis were performed. RESULTS: The two strategies for blood conservation which were predominantly used were aprotinin therapy (78%) and blood salvage from the extracorporeal circuit (68%). During perioperative period, 42% of patients [95% CI: 37-47%] received allogenic transfusion. The haemoglobin threshold for transfusion was 7.4 +/- 1.1 and 8.0 +/- 0.7 g x dl(-1) in operating room and in intensive care unit, respectively. On average, 3.4 +/- 2.7 units of red cell concentrates were transfused perioperatively per patient. Using multivariate analysis, perioperative allogenic transfusion was significantly associated with the following variables: preoperative haemoglobin level < 12 g x dl(-1) (odds ratio 8.9; p = 0.001), emergency procedure (odds = 3.7, p = 0.01), reoperation (odds ratio = 3.3; p = 0.002), chronic obstructive pulmonary disease (odds ratio = 2.5; p = 0.03) and complex surgery (odds ratio = 2.4; p = 0.01). The age, the gender, and body mass index were only independent risk factors by univariate analysis. CONCLUSION: In despite of techniques to limit requirement of allogenic transfusion, a large proportion of cardiac surgical patients remains transfused. Independent risk factors of perioperative transfusion are haemoglobin level < 12 g x dl(-1), emergency procedure, reoperation, chronic obstructive pulmonary disease and complex surgery.     

HAEMODILUTION STUDY IN MAJOR ORTHOPAEDIC SURGERY EXPERIENCE AS A TECHNIQUE OF BLOOD CONSERVATION

Haemodilution and auto-transfusion were carried out in 103 consecutive patients having major orthopaedic surgery. The records of 99 patients were available for retrospective assessment of this technique. Fifty-six per cent of the patients did not require any homologous blood transfusion. Homologous blood transfusion was given to 44% of the patients, who used up 99 units of blood in their entire hospital stay. There was no morbidity such as transfusion reaction, infection, decrease in platelets or re-operation for bleeding associated with the procedure, although there was one death secondary to myocardial infarction. This technique offered an alternative method to reduce the use of homologous blood transfusion in major orthopaedic operations.     

Impact of surgeon volume and specialization on short-term outcomes in colorectal cancer surgery

BACKGROUND: Several studies have shown a relationship between surgeon volume and outcomes in colorectal cancer surgery. The aim of this study was to determine the impact of surgeon volume and specialization on primary tumour resection rate, restoration of bowel continuity following rectal cancer resection, anastomotic leakage and perioperative mortality. METHODS: The Northern Region Colorectal Cancer Audit Group conducts a population-based audit of patients with colorectal cancer managed by surgeons. This study examined 8219 patients treated between 1998 and 2002. Outcomes were modelled using multivariate logistic regression analysis. RESULTS: Tumour resection was performed in 6949 (93.8 per cent) of 7411 patients. High-volume surgeons with an annual caseload of at least 18.5 (odds ratio (OR) 1.53 (95 per cent confidence interval (c.i.) 1.10 to 2.12); P = 0.012) and colorectal specialists (OR 1.42 (95 per cent c.i. 1.06 to 1.90); P = 0.018) were more likely to perform elective sphincter-saving rectal surgery. In elective surgery, the risk of perioperative death was lower for high-volume surgeons (OR 0.58 (95 per cent c.i. 0.44 to 0.76); P < 0.001), but this was not the case in emergency surgery. CONCLUSION: High-volume surgeons had lower perioperative mortality rates for elective surgery, and were more likely to use restorative rectal procedures.     

Value of the Glasgow Aneurysm Score in predicting the immediate and long-term outcome after elective open repair of infrarenal abdominal aortic aneurysm

BACKGROUND: This study aimed to explore the value of the Glasgow Aneurysm Score in predicting the immediate and long-term outcome after elective open repair of abdominal aortic aneurysm (AAA). METHODS: Some 403 patients underwent elective open repair of an infrarenal AAA and were classified retrospectively according to the criteria of the Glasgow Aneurysm Score (risk score = (age in years) + (7 for myocardial disease) + (10 for cerebrovascular disease) + (14 for renal disease)). RESULTS: Fourteen patients (3.5 per cent) died after operation, 23 (5.7 per cent) had a myocardial infarction and six (1.5 per cent) had a stroke. One hundred and nine patients (27.0 per cent) experienced severe postoperative complications. The Glasgow Aneurysm Score was predictive of postoperative death (area under the receiver-operator characteristic curve (AUC) 0.80, 95 per cent confidence interval (c.i.) 0.71 to 0.90), severe postoperative complications (AUC 0.67, 95 per cent c.i. 0.61 to 0.73), myocardial infarction (AUC 0.72, 95 per cent c.i. 0.62 to 0.82), myocardial infarction-related postoperative death (AUC 0.78, 95 per cent c.i. 0.63 to 0.94) and stroke (AUC 0.84, 95 per cent c.i. 0.74 to 0.95). Univariate analysis showed that this risk index was also predictive of long-term survival. CONCLUSION: The Glasgow Aneurysm Score is a good predictor of outcome after elective open repair of AAA. Its simplicity and accuracy make it useful for preoperative risk stratification.     

A reduction in type and screen: preoperative prediction of RBC transfusions in surgery procedures with intermediate transfusion risks

In many patients, a 'type and screen' procedure is routinely performed before surgery. However, most patients are not transfused after all. Can we predict, which surgical patients will and will not be transfused, to reduce the number of these investigations? We studied 1482 consecutive surgical patients with intermediate risk for transfusion. Multivariate logistic regression modelling and the area under the Receiver Operating Characteristic curve (ROC area) were used to quantify how well age, gender, surgical procedure, emergency or elective surgery and anaesthetic technique predicted transfusion, and whether the preoperative haemoglobin concentration had added predictive value. Gender, age > or =70 yr, and type of surgery were independent predictors of transfusion, with a ROC area of 0.75 (95% CI: 0.72-0.79). Validating this model with an easily used prediction rule in a second patient population yielded a ROC area of 0.70 (95% CI: 0.63-0.77). With this rule type and screen could correctly be withheld in 35% of these patients. In the remaining 65% of the patients, a further reduction in type and screen investigations of 15% could be achieved using the preoperative haemoglobin concentration. Using a simple prediction rule, preoperative type and screen investigations in patients who have to undergo surgery procedures with intermediate transfusion risk can be avoided in about 50%. This may reduce patient burden and hospital costs (on average: 3 million US$ per 100 000 procedures).     

Cholesterol and serum albumin as risk factors for death in patients undergoing general surgery

BACKGROUND: Serum levels of total cholesterol, its fractions (high-density lipoprotein-cholesterol (HDL-C) and low-density lipoprotein-cholesterol) and albumin are related to a poor outcome during hospital stay. It has been not assessed whether they are related to death in the long term after general surgery. METHODS: This prospective cohort study included 2848 general surgical patients with a median follow-up of 6 years after discharge from hospital. Sampling for biochemical measurements was done at the time of admission. The outcome investigated was all-cause mortality and multivariable Cox regression was used for statistical analysis. RESULTS: Three hundred and seventy-eight patients (13.3 per cent) died during follow-up. Serum albumin (adjusted hazard ratio (HR) 2.2 (95 per cent confidence interval (c.i.) 1.5 to 3.4) for lowest versus highest quintile), total cholesterol (HR 1.6 (95 per cent c.i. 1.1 to 2.3) for lowest versus highest quintile) and HDL-C (HR 1.6 (95 per cent c.i. 1.1 to 2.4) for lowest versus highest quintile) showed a significant inverse relationship with all-cause mortality in both crude and multivariable analyses. Serum albumin and HDL-C were associated with death for up to 2 years after surgery, whereas total cholesterol had the strongest association more than 2 years after discharge. CONCLUSION: Low levels of serum albumin, total cholesterol and HDL-C are associated with death after discharge from hospital in patients having general surgery.     

Laparoscopic ultrasonography is a complement to cholangiography for the detection of choledocholithiasis at laparoscopic cholecystectomy

BACKGROUND: Intraoperative cholangiography and laparoscopic ultrasonography are both used in the detection of common bile duct stones at laparoscopic cholecystectomy. The aim of this prospective study was to determine whether laparoscopic ultrasonography has an alternative or a complementary role with respect to cholangiography in achieving this end. METHODS: The biliary trees of 900 patients undergoing laparoscopic cholecystectomy were examined routinely by the two methods. The diagnostic power of each investigation and of the two techniques in combination was evaluated. The statistical non-random concordance between the two methods was also determined. RESULTS: Laparoscopic ultrasonography was performed in all 900 patients. Cholangiography was performed in 762 (85 per cent). The mean (range) duration was 9.8 (4-21) min for laparoscopic ultrasonography and 17.6 (7-42) min for cholangiography. For the detection of common bile duct stones, with a kappa coefficient of 0.57 (95 per cent confidence interval (c.i.) 0.43 to 0.71), the non-random concordance between the two methods was considered to be fair to good. The sensitivity of laparoscopic ultrasonography was 0.80 (95 per cent c.i. 0.65 to 0.91) and its specificity was 0.99 (95 per cent c.i. 0.98 to 1.00). The respective values for cholangiography were 0.75 (95 per cent c.i. 0.59 to 0.87) and 0.99 (95 per cent c.i. 0.98 to 1.00). The examinations combined had a sensitivity of 0.95 (95 per cent c.i. 0.86 to 0.99) and a specificity of 0.98 (95 per cent c.i. 0.96 to 1.00). CONCLUSION: Laparoscopic ultrasonography and intraoperative cholangiography are complementary, as the combination of both methods maximizes the intraoperative detection of choledocholithiasis.     

Predicting the survival of patients with peritoneal carcinomatosis of colorectal origin treated by aggressive cytoreduction and hyperthermic intraperitoneal chemotherapy

BACKGROUND: Peritoneal carcinomatosis in the absence of distant metastasis occurs in approximately 8 per cent of patients with colorectal cancer. Cytoreduction followed by hyperthermic intraperitoneal chemotherapy (HIPEC) is a new treatment option. Patient selection is crucial to outcome. METHODS: Cytoreduction followed by HIPEC was performed in 102 patients with peritoneal carcinomatosis. The following factors were studied for association with survival: perforation and obstruction of the primary lesion, location of the primary lesion, obstruction associated with carcinomatosis, presentation, tumour differentiation and histological type. Extent of disease and completeness of cytoreduction were also studied. Hazard ratios (HRs) were used to study these factors. RESULTS: Location of the primary tumour in rectum (HR 3.14 (95 per cent confidence interval (c.i.) 1.11 to 8.91); P = 0.069), poor differentiation (HR 1.73 (95 per cent c.i. 1.04 to 2.88); P = 0.031) and signet cell histological type (HR 2.24 (95 per cent c.i. 1.21 to 4.16); P = 0.008) were associated with shorter survival. Important factors predicting survival were the number of affected regions (HR 1.38 (95 per cent c.i. 1.20 to 1.59); P < 0.001), the simplified peritoneal cancer score (HR 1.19 (95 per cent c.i. 1.12 to 1.26); P < 0.001) and completeness of cytoreduction (HR 8.54 (95 per cent c.i. 4.01 to 18.18); P < 0.001). No other factor correlated with survival. CONCLUSION: The survival of patients with peritoneal carcinomatosis of colorectal origin is dominated by the extent of disease and the amount of residual tumour after cytoreduction.     

Improving the ability to predict mortality among burn patients

BACKGROUND: Early efforts to predict death following severe burns focused on age and burn size; more recent work incorporated inhalation injury and pneumonia. Gender, co-morbid illness, and co-existent trauma have been implicated in burn mortality but have rarely been incorporated into predictive models. METHODS: The National Burn Repository (NBR) and the National Trauma Data Bank (NTDB) provided data on 68,661 (54,219 and 14,442, respectively) burn patients that was used to develop and validate, respectively, a predictive model of burn mortality. Logistic regression was used to model the odds of mortality with respect to age, gender, % body surface area burned (BSAB), co-existent trauma, inhalation injury, pneumonia, and co-morbid illness. Performance of the predictive model was assessed using a deviance statistic, receiver operating characteristic (ROC) curves, and the Hosmer-Lemeshow (HL) statistic. RESULTS: The predictive model that demonstrated optimal performance included the variables age, percent total BSAB, inhalation injury, co-existent trauma, and pneumonia. The area under the ROC curve for this model was 0.94 and the HL statistic was 16.0. The inclusion of additional variables, i.e., gender, co-morbid illness, did not improve the performance of the model despite reduction in the model deviance. When the predictive model was applied to the validation data source, the area under the ROC curve was 0.87 and the HL statistic was 10.0, indicating good discrimination and calibration. CONCLUSION: The results of this study suggest that a comprehensive predictive model of burn mortality incorporating certain variables not previously considered in other models provides superior predictive ability.